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A pilot project that administered directly observed therapy with highly active antiretroviral therapy (DOT-HAART) to people living in a "poor community in rural Haiti" produced positive results, demonstrating that drug therapy can be successfully implemented in low-income areas and developing nations, according to new research published in the Aug. 4 issue of the Lancet. In the 60-person study, Dr. Paul Farmer and colleagues implemented in rural Haiti a DOT-HAART program modelled after "successful tuberculosis-control efforts." The program paired each HIV-positive participant with a "companion" -- often a community health worker -- who observed the patient's medicine intake. The companion also responded to patient and family concerns and offered "moral support." "Social support," such as assistance with children's school fees, was also given to study participants, and patients met once a month to discuss "their illness and other concerns." The researchers report that response to the DOT-HAART regimen was "dramatic" and that side effects were "rare and readily managed by community health workers and clinic staff." The study also shows that the
HIV-positive people who received HAART were "far less likely" to require hospitalization than patients with "untreated" HIV.

Treatment Must Complement Prevention
Farmer and colleagues write that although many policy makers and others have stressed prevention as key to stemming the spread of HIV, "the prevention strategies currently in use will not inflect HIV incidence among the poorest populations." They state that although prevention efforts "merit greater support," other "complementary strategies" such as vaccination efforts and antiretroviral treatment are needed. Political violence and resulting migration, as well as gender inequality and poverty, have "conspire[d] to make the male condom an imperfect prevention measure" and have hampered prevention efforts, they write. However, they state, antiretroviral therapy "can reinvigorate flagging prevention efforts," reduce the stigma associated with HIV and increase the demand for HIV testing and counseling.

Building a Better Treatment Regimen
The researchers add that although some critics contend that HAART "is too complicated for settings without specialists to guide therapy," modifications in the drug regimen can be made to accomodate the health systems of developing nations. They suggest implementing a treatment regimen that employs a combination of two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor instead of a protease inhibitor. A combination of zidovudine, lamivudine and abacavir, three NRTIs, is also a "promising possibility" because it would be "significantly simpler than tuberculosis treatment and would preserve protease inhibitors and non-nucleosides for cases of suspected or documented treatment failure," they write. In addition, implementing drug treatments that do not use NRTI monotherapy could prevent the development of drug-resistant strains of HIV. There is also "reason to believe that minor modifications could improve local capacity to care for those sick with advanced HIV disease," the researchers state. Evidence supporting this statement, they continue, lies in the fact that the research team led a DOT-HAART project "in one of the poorest parts of the poorest country in the Western hemisphere" and in the fact that other chronic infections "have been well managed in equally poor countries." The scientists conclude with a proposal for a "basic minimum package for HIV in endemic settings" that includes post-exposure prophylaxis for rape and professional accidents; aggressive AIDS prevention programs, including barrier methods; mother-to-child transmission prevention packages, including milk supplements; social assistance to the families of HIV-positive individuals, including orphans; diagnosis and treatment of opportunistic infections and sexually transmitted diseases; and DOT-HAART therapy (Farmer et al., Lancet, 8/4).

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